Treatment for Ramsay Hunt Syndrome
Patients with Ramsay Hunt syndrome should be treated immediately with combination therapy of oral antivirals (acyclovir 800 mg five times daily or famciclovir 500 mg three times daily) plus oral corticosteroids (prednisone 60 mg daily) for 7-10 days, initiated as early as possible after symptom onset. 1
Primary Treatment Regimen
- Start antiviral therapy immediately with either acyclovir 800 mg five times daily or famciclovir 500 mg three times daily for 7-10 days 1
- Combine with oral corticosteroids: prednisone 60 mg daily for 3-5 days 1
- The combination of steroids plus antivirals achieves 70.5% complete recovery (House-Brackmann grades I-II) compared to 68% with steroids alone 2
Timing is Critical
- Early treatment is essential - initiate therapy within 7 days of symptom onset for optimal outcomes 1
- Delayed treatment significantly reduces recovery rates, particularly in patients with complete facial palsy 2
- Even patients presenting with vesicles after facial weakness onset should receive immediate treatment 3, 4
Steroid Selection Matters
The type of corticosteroid affects recovery rates when combined with acyclovir 2:
- Methylprednisolone: 81.3% complete recovery
- Hydrocortisone: 76.3% complete recovery
- Prednisone: 69.2% complete recovery
- Prednisolone: 61.4% complete recovery
Salvage Therapy for Non-Responders
- For patients not recovering after standard oral therapy, consider intravenous high-dose methylprednisolone even as a late treatment option 5
- This approach has shown near-complete recovery in patients with poor prognostic factors including high-grade facial weakness and absent blink reflex responses 5
Supportive Care Requirements
- Perform audiometric evaluation at the conclusion of treatment and within 6 months to assess hearing recovery 6
- Counsel patients with residual hearing loss and/or tinnitus about audiological rehabilitation and supportive measures 6
- Provide eye care for lagophthalmos to prevent corneal complications 4
Important Clinical Considerations
Ramsay Hunt syndrome has worse prognosis than Bell's palsy - patients are less likely to recover completely and often have more severe paralysis at onset 1. Among patients with complete facial palsy (grades V-VI), only 51.4% recover to grades I-II 2.
Do not delay treatment waiting for vesicles - 14% of patients develop vesicles after facial weakness onset, making early Ramsay Hunt syndrome indistinguishable from Bell's palsy 1. Some patients have "zoster sine herpete" with no rash at all 1.
Avoid routine use of other agents - do not prescribe thrombolytics, vasodilators, or vasoactive substances as they lack documented efficacy 7
Poor Prognostic Factors to Recognize
Patients with the following features require particularly aggressive treatment 5:
- Advanced age at onset
- High-grade facial weakness (House-Brackmann V-VI)
- Absence of R1 and R2 response on blink reflex testing
- Involvement of greater superficial petrosal nerve